Public Health Dental Hygiene Dental (PHDHP) Survey

I. DEMOGRAPHICS

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* 1. Location of personal residence (zip code)

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* 2. Location of primary practice site (zip code)

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* 3. Do you currently hold a PHDHP license?

YES

NO

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* 4. If answered YES to Question #3, list license number and date issued:

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* 5. Are you eligible for PHDHP licensure?

YES

NO

NOT SURE

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* 6. Do you currently hold a Local Anesthesia license?

YES

NO

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* 7. If answered YES to Question #6, list license number and date issued:

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* 8. Are you currently a School Certified Dental Hygienist?

YES

NO

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* 9. Are you currently a Member of the ADHA?

YES

NO